- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.46 / $675.20 / $2,488.41
| Professional | | $508.46 | $675.20 | $2,488.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.45 / $773.45 / $773.45
| Facility | | $773.45 | $773.45 | $773.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.47 / $657.66 / $773.45
| Professional | | $341.47 | $657.66 | $773.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.10 / $493.36 / $773.45
| Facility | | $383.10 | $493.36 | $773.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.99 / $734.03 / $997.50
| Professional | | $460.99 | $734.03 | $997.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.87 / $755.16 / $871.04
| Professional | | $621.87 | $755.16 | $871.04 |